Michael White on NHS reform

In the event, I got to line nine before feeling mildly irritated by the assertion that "the NHS is facing a perfect storm - an ageing population, expensive new technology and a more informed society. The compliant stoicism of post-war Britain has evaporated.''

Later the authors, Nick Bosanquet, Andrew Haldenby and Helen Rainbow, explain that the perfect storm comprises obesity, migration, technology and life expectancy. But, of course, all healthcare systems face these problems in varying degrees.

So it's not just us, it's not all hopeless, though I had to read until page 45 to encounter something cheerful: ambulance crews in London are now doing much better on in-street cardiac procedures. I didn't know that.

As for "compliant post-war stoicism'', I don't think that's how Aneurin Bevan regarded the militants of the British Medical Association in 1948 as he manoeuvred them into accepting the NHS. The point is topical because - though progress can be painfully slow, Reform is right about that - the BMA has conceded that its GP members will provide an extra three hours (average) a week of face-time for patients. Or customers, as we call them now.

By my calculation this may be the first modest feather in Alan Johnson's cap as health secretary. After the unintended consequences of the new contracts (pause for cheers of BMA gratitude), he and Gordon Brown had made GP flexibility an explicit target and won.

Why? After all, BMA negotiators, the toughest trade union of the lot Ken Clarke conceded on the radio, often "do a Darzi'' on the NHS side: slit them open and stitch them up again. This time they may have felt themselves out of step with public opinion and even with GPs.

Comrade Al, himself a former union negotiator, was also involved directly in the talks.

"Alan's a class act, he's negotiated from both sides of the fence, he knows when to push and when to go silent,'' explains one admirer.

Three hours a week may not change the lives of many patients but it helps set the pace and direction. That's where I think the Reform paper gets it a bit wrong. It's coherent and, of course, intelligent. It promotes patient power, independent commissioning, more competition between providers, flexible labour policies and NHS pricing and the (fashionable) separation of regulation from political and strategic responsibilities in what it calls "the last and largest of the nationalised industries'.'

Reform's paper concedes that Brown-Johnson sort of know this, hence the title about mantras, though ministers no longer bang on about it quite so much (counter-productive?). But the authors give no inkling of how difficult it all is, and might still be even if every last bedpan was privatised.

That must be why the paper and supporting data make little mention of US healthcare, a fascinating case of extensive market failure. But do read it: you can then explain the table on page 19 which appears to suggest that no one ever dies of a stroke in Germany. Match that, Johnson!

By chance last week I listened to senior public sector managers grappling with these problems: how to get Whitehall off their backs but still maintain the momentum of reform at local level. Most of us know what to do: less structural reform, more of the behavioural kind; how to achieve it is the issue.

Or as one wit put it, when Whitehall tells us to be free, we reply, "Tell us how to be free.'' Be free to seek "forgiveness, not permission'' - forgiveness when things go wrong - was how cabinet secretary Sir Gus O'Donnell put it in a memorable phrase.

My star of the day was Clare Chapman, who has moved from running Tesco's workforce to running the NHS's. There's no silver bullet, it may take years of pushing the same spot until you get that breakthrough, she said. She has brought with her Tesco's mantra, "Is it better (for the customer), simpler (for staff) and cheaper (for Tesco)? If Yes, do it." Wonderful stuff. I may have to send Clare a Valentine.